Provider Demographics
NPI:1356861975
Name:MANSOORI, ANISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:MANSOORI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27800 MEDICAL CENTER RD STE 220
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6408
Mailing Address - Country:US
Mailing Address - Phone:949-545-6605
Mailing Address - Fax:949-326-7509
Practice Address - Street 1:27800 MEDICAL CENTER RD STE 220
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6408
Practice Address - Country:US
Practice Address - Phone:949-545-6605
Practice Address - Fax:949-326-7509
Is Sole Proprietor?:No
Enumeration Date:2017-06-24
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8205207N00000X
CAA125067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology